Sunday, November 22, 2009

This week, the revised U.S Preventive Services Task Force (USPSTF) mammography guidelines monopolized newsprint and airtime. Was this truly Page 1 news? For a few days, mammojournalism pushed aside stories on the war in Afghanistan, double digit unemployment, Iran’s hidden nukes, the president’s foreign nation tour and the war on terror.

(Note to readers: The phrase ‘war on terror’ is now verboten in the the Obama administration. No spokesmen will utter it, except on deep backround. I unabashedly use it since it seems that our enemies are still at war with us.)

Of course, it’s not the science of mammography that is white hot – it’s the politics of breast cancer that is volatile and combustible. Medical guidelines in every specialty are revised regularly, yet no conflagration erupts in the public square, as occurred last week. When my own specialty revises colonoscopy guidelines every few years, the public and the medical community respond with a collective yawn. Not so for breast cancer,which has lobbyists and political muscle that fights to make sure that their cause remains a national priority. Even mainstream medical organizations and public advocacy groups are in their corner. Maggie Mahar writes at HealthBeat that the initial reaction from many health professionals, breast cancer survivors and advocates has been outrage and anger, with many insisting that women’s health will be compromised if these recommendations are implemented...Leading this onslaught are some key members of the cancer establishment: The American Cancer Society, The American College of Radiology and the National Cancer Institute.

First, the USPSTF was accused of being a tool of medical cost control fanatics. I agree there was bias – from the accusers, not from the USPSTF. The mammogram brigades had an agenda and weren’t going to be derailed by solid medical data. The USPSTF has earned a reputation for objectivity and caution. They do not make recommendations that are beyond the data, despite political pressure to do so. Unlike most medical societies and advocacy groups, they are skeptical and conservative, two qualities that are often lacking in the medical arena. They should be applauded for calling it like they see it. Instead, they are chastised by those who are distressed by their recommendations. However, just because we dispute the outcome, doesn't mean that the system is flawed. For example, if we don’t like a jury’s verdict, does it mean that the trial was unfair?

Preventive medicine is overrated, a heretical statement from a physician who performs screening colonoscopies. While I support mammography and colon cancer screening, their medical benefits are much more modest than the public realizes. With respect to mammography, the data demonstrating meaningful benefit to women, particularly those under 50, have always shown relatively small gains for them. This test is often portrated as a lifesaver, but this is an exaggeration. Yet, there is a juggernaut of support for annual exams behind it.

What about the downsides of yearly mammograms for average risk women in their 40s? In addition to the test’s limited efficacy in this group, here are some real concerns from overuse.

Radiation

Anxiety for patients and families

False postive results which lead to invasive medical care

Detecting cancers that may never progress.

Of course, cost is also a factor, even though the USPSTF is prohibited from considering it in their deliberations. Where is the data that yearly mammograms in younger women are cost effective? This is analogous to the PSA test in men for prostate cancer. How many men are harmed by the PSA in order to save a single life? You cannot argue that saving a life is worth any cost, as this is not how our society operates. We all know that if we lowered the highway speed limit to 40 mph, or raised the driving age to 25, that we would save lives. Yet, we do not demand these revisions. We accept low risks of catastrophic events in our daily lives.

The USPSTF revisions are being co-opted by the political right as a prelude to medical rationing. I reject this broadside, just as I do the protests from the medical left, whose enthusiasm for mammography exceeds the evidence. If rationing means that every American cannot have every available medical benefit on demand, than I am a rationer. Of course, we all know that loaded terms like rationing are routinely sanitized to make them more palatable, even if their meaning doesn’t change. Here are a few sanitization examples.

New & Improved Sanitized Descriptions

Global War on Terror morphs to Overseas Contingency Operation

Medical Rationing is scrubbed to Evidenced Based Medicine

Whistleblower is buffed into Truth-teller

Interestingly, Kathleen Sebelius, Secretary of the Department of Health and Human Services, is sprinting at top speed away from the new USPSTF guidelines. I hope she doesn’t collapse from exhaustion. I am troubled by her retreat, as are fellow medical bloggers Medrants and The Covert Rationing Blog. The Obama administration is devoting over $1 billion dollars to fund comparative effectiveness research (CER), which is supposed to use solid medical data to determine which treatments actually work. Its objective is to eliminate ineffective care, which would result in billions of dollars of cost savings. Now, the USPSTF, appointed by the federal government, has issued solid CER guidelines that our government is rejecting with alacrity and zeal. Anyone want to wager on whether CER has a prayer to succeed? The Health Care Blog notes that our government's revised CER policy is 'not on our watch'.

The USPSTF presently endorses screening colonoscopy between the ages of 50 and 75. In the forseeable future, this guideline will be revised, when new technology replaces this procedure. When this occurs, should I welcome a development that will serve humanity, or grab a pitchfork and a microphone and cry foul. One of the most intractable challenges in health care reform is to separate one’s own interest from the public interest. If there is to be any chance of success, we need to be governed by science and medical evidence. The mammography mania we have just witnessed demonstrates that we are not equal to the task. The public and many physicians are convinced that more medical care means better health, a fallacy that may take at least a decade to unravel. This is the Gordian Knot of health care reform.

23 comments:

I agree that the instant rebellion against the new recommendation, with no look at all at the evidence or the reasons for it, is typical of the worst sort of media- and lobbyist-fueled panic. And I think you're right: the word "rationing" is thrown into the discussion by the Right as a Molotov cocktail to reduce the possibility of rational discussion (which is generally hard on the Right, as well as being difficult for the Right).

I don't think the phrase "war on terror" is useful. Nor is "war on crime" or "war on waste". "War" has a useful meaning, and it goes beyond merely fighting. One test for whether the word "war" is being properly used: will the struggle being waged end with a surrender ceremony and treaty? If not, it's not a war. It may be a fight, but it has no specific end.

Unfortunately, Obama has on occasion shown signs of political cowardice and shallow commitment to principle (as in his fighting to keep secret the details of US torture program and the investigation and possible prosecution of those responsible, even though he has said that we don't do that anymore).

Thanks for your comments on my blog. Sebelius should have stood by her team, but she didn't. Of course, I would expect nothing less from Secretary Sebelius - someone so out of their league that her only qualification for the job was raising money for Candidate Obama. Let's face it, Sebelius is a joke. But we knew that months ago.

But, with that said, it's tough to defend the USPSTF recommendations. They, quite frankly, are crap. I'm all in favor of evidence-based medicine, but let's have evidence - solid, quality studies. From 2002 to this round, there was only one new study, which was inconclusive at best. The change wasn't in medicine, the change was in the political landscape and how we view cost-control measures (CMS did provide a briefing on USPSTF on cost of screening, so we know that "resource requirements" were taken into account in the USPSTF recommendations).

So, instead of evidence-based USPSTF recommendations, we got a bunch of pediatricians, psychiatrists and healthcare economists making recommendations on things they know little to nothing about. It's tough to say you've got evidence-based medical guidelines for adult breast cancer when there isn't a single oncologist in the room. Kind of a joke really. I want to know how much clinical experience the 4 pediatric providers brought to this discussion?

Everyone should ignore the USPSTF recommendations, until such time as USPSTF comes up with medically-based recommendations. If those medically-informed guidelines support scaled back screening, I will support it. However, let's not mistake the USPSTF recommendations for being informed by science. This was only an exercise in politics.

The most disappointing aspect of Sebelius's conduct is that she trashed the process. Comparative effectiveness research (CER) is an absolute necessity for meaningful health care reform. As I have posted earlier on this blog, this process will create winners and losers. There will be great resistance and pushback from those who may lose income or entire industries. These are the obstacles that must be overcome if we are to succeed. Last week, our government, ostensibly committed to reform and CER, caved. They have committed over $1 billion to CER, but I wonder now what kind of CER do they have in mind?

I am trying to understand the "statistical" approach of the USPSTF regarding how medicine should be practiced. Does anyone go to these statistician/MDs for diagnosis and treatment based only on averages and not on individual nuances of diagnosis, current best treatment practices, and individual experiences with an illness? Scientists know that correlations do not indicate cause and effect. There could be many reasons why some are overtreated following cancer detection. It could be that on average MD's just aren't very good -- so let's rank MD's based on their outcomes. It could be that we get too frightened when we hear the word cancer so let's educate ourselves as to the degrees of threat from various levels of cancer. Meanwhile let's look at the "best" cases, folks whose screening results in uncovering cancer that is then eliminated with minimum side effects before it metastasizes. Rather than focusing on reducing screening, which is clearly effective in many many cases, even if a minority -- let's focus on the success stories and the experts in a disease who deal with individual successes with the latest techniques, not the statisticians who deal only mass outcomes using approaches which are often already outmoded, and see what we can learn to help the average and below overage outcomes become more successful.

By way of analogy to USPSTF recommendations on screening, let's imagine a socio economic group that on average does poorly in higher education. If we followed the "task force" approach of the USPSTF we would say, let's not waste money and resources trying to educate these folks --- look at how bad the outcomes are for so many of them. Is that really the world we want to live in or should we see how to create more successful outcomes. The same goes with screening in my opinion. It clearly provides important life defining information for some of us --- so why is USPSTF so ready to throw us out as meaningless exceptions? It would seem to me that the successes, even if a minority, prove the worth of screening and USPSTF should study those and compare them to the failures, and then draw conclusions as to what to do right, rather than trying to reduce screeing because of the failures. If you had the unfortunate experience of being diagnosed with breast cancer or prostate cancer, would you go to the USPSTF to get an opinion on what to do next? Of course not, because they only deal with statistics and averages. We all seek ways to be above average and to raise the average. If you want to be average, follow the USPSTF suggestions. However if you want to be treated as a unique individual, and to get the best possible treatment, and to have your own variations in diagnosis and disease taken into account go to specialists in the disease, several for a range of opinions and chart your own future as best you can, beginning with screening.

Continuing, can USPSTF prevent scientific evidence re likely outcomes if best practices are followed as described for example by NCCN or AUA? Are there data as to the course of treatment for the hordes of people in their studies? Is there any reason to not still go for the best course as described by the true experts in a particular disease?

Lee, I thank you for your comments. As we have discussed with prostate cancer, the medical issue is beyond the question, how many individuals will the screening test save? It must be balanced against how many people will be harmed by the test. This is why I have been hostile to the PSA screening test for prostate cancer. You could use your logic to advocate for screening mammography for women in their 30s, or younger, since it is possible to contract breast cancer at a young age. We do not screen entire populations for preventable diseases. Based on expert opinion, we do so at certain ages based upon various factors. Of course, sometimes we deviate from these recommendations, but only for a particular reason. I am not invoking cost control, although it is highly relevant, but only medical utility. When tests are done too liberally, the results are more likely to be false positive results, which can lead to a hazardous medical cascade.

I find it difficult to be objective when viewing the new USPSTF guidelines while my sister is scheduled for a mastectomy next week and two sisters-in-law have had breast cancer... all under the age of 50, all unrelated, all with no family history, all detected on routine yearly mamms. These were not "A" recommendations, but I've yet to see any reporting to the public about the way in which the USPSTF grades recommendations in relation to the strength of the evidence.

Breast cancer is so politicised that it may be impossible to institute changes. For example congress passed legislation allowing women to bypass their doctors and go directly to imaging centers for mammagraphy. As a consequence, radiologists send post cards annually reminding women to come in without having those important patient physician discussions we hear so much about. The post cards must stop! The senate's healthcare reform bill will create an independent commission with the power to bend the Medicare cost curve. But if what happened with the USPSTF recommendations last week is any indication of the potential of this to work we're in trouble!

USPSTF "conclusions" are based on mass statistics without looking at the trajectories of individuals re the follow ups on screening. I have previously hypothesized that two factors that reduce the effectiveness of screening, e.g. mammograms and PSA tests, if early stage cancers are discovered are --1. the gut reaction fear that tends to induce many to seek overtreatment without consideration of the options and 2. inadequate medical procedures performed by physicians with poor skills. Solutions to help improve the efficacy of the important information that screening can provide are thus better education of patients prior to being diagnosed with cancer, and two better physicians or minimally more information for patients re outcomes for individual physicians. A paper has just come out providing support for the second hypothesis -- it clearly shows that many prostatectomies are performed by surgeons with limited training and presumably inadequate skills resulting in poor outcomes which, in the USPSTF crude approach would weaken the case for screening. The appropriate way to get positive outcomes for large populations is to get positive outcomes for the individuals making up the populations. If the major factors influencing outcome are not taken into account, then the fact that a gross average over one variable doesn't show benefits is immaterial --- the question is how to optimize the positive effect of screening -- this optimization will tell you how useful it is -- and how to make it useful. According to the new study, the majority of prostatetectomies in this country are performed by surgeons with extremely limited experience resulting in a substantial reduction in effectiveness and increase in negative side effects. But wait you say, what does that have to do with PSA screening. Simple --- many of the men getting inferior treatment had their initial diagnosis via psa screening. So a study by USPSTF which just looked at PSA and at final outcome would "conclude" that the PSA screening didn't work, when what really didn't work was a further step the surgery because of the incompetence of the surgeons. USPSTF needs to look at these sorts of factors before coming up with much in the way of useful conclusions in my scientific opinion, or else all they should conclude is that you don't have good followup available don't get mammograms and PSA tests. More importantly --- we need advice on how to get qualified practitioners, not on avoiding obtaining potentially useful knowledge about whether or not we have early stage cancer.

From the report:www.medscape.com/viewarticle/713012?sssdmh=dm1.560691&src=nldne&uac=121910CN November 25, 2009

The majority of surgeons performing radical prostatectomy in the United States have extremely low annual caseloads, which can result in an increased risk for surgical complications and cancer recurrence, according to a new analysis published in the December issue of the Journal of Urology.

"focus on the success stories and the experts in a disease who deal with individual successes with the latest techniques, not the statisticians who deal only mass outcomes "

Hello? So you are telling that plural of anecdotes should have more weight than real data? So shall we also replace statisticians who work for pharmaceutical companies evaluating data from studies to see if a particular drug works with disease specialists so that they can tell us about anecdotal reports of patients taking the drug?

How would disease specialists determine the mortality reduction? By telling us how long somebody survives after diagnosis? Can you spell lead-time bias? How would disease specialists who only see sick people and couldn't care less about healthy people whose blood pressure goes up after each false positive (or in some cases even before a routine mammogram) determine the extent of false positives, the number of biopsies, etc.? And what about overdiagnosis? The only way to determine overdiagnosis is by correlation of data. And yes, the longer we are from the mammogram studies the more data about overdiagnosis in original studies becomes available. This is the job for people who kow statistics. The longer we are in history of having mammograms, the more data there is.

NJ - the problem with overdiagnosis is that every single woman overdiagnosed thinks her life was saved by mammograms. Nobody can tell if a specific early cancer like in your sister or your sisters in-law would've ever progressed had it remained undetected. Nobody can tell if a specific cancer is sufficiently slow growing that even had it been detected later when you noticed the tumor it would still be localized in the breast. And in some cases, the cancer would still kill. This is the main thing that people who've seen cancer detected on mammograms don't understand. Yes, mammograms certainly detect more cancer. In fact, the incidence of cancer is much higher in women that do mammograms than in those that don't, and those that don't never catch up. But the issue is not how many cancers mammograms detect, the issue is how many lives they save and how many people are harmed in the process.

Not every cancer detected by mammograms corresponds to lives saved. This is why statisticians and not oncologists look at the data: oncologists only look in cases like you describe. Epidemiologists look at the numbers: extra cases of early cancer diagnosed vs cases of advanced cancers diagnosed later vs lives saved.

Lee Smith -- have you read about Japan experience with screening for neuroblastoma? Do you think it were "disease specialists" who determined that this was a total failure or statisticians? If not for statisticians, how many kids would've still been diagnosed with cancer and suffered from side effects of the treatment with no lives saved?

Diora: Isn't it obvious that if more PSA screened men went to better surgeons following screening, there would be more successful outcomes? Do the statisticians take into account factors like this before reaching conclusions about the effectiveness of screening? Let's assume each stage in a process has some probability of success less then one. The overall success is then the product of all the probabilities. Making up an example -- of a two stage process -- say the probability of stage 1, successful screening, was 90% and the probability of stage 2, successful surgery was 50%. Then the probability of over all success would be 45%. If the the probability of stage 2 increase to 70%, then the overall probability of success would incrase to 63%. So my question is -- in evaluations of the usefullness of screening, were the results corrected for likely inadequate practitioners -- radiologists, pathologists, surgeons, oncologists, etc.

I find it difficult to read through your post and understand it when some of your basic understandings of breast cancer diagnosis and risk seem flawed. Mammography is not preventive medicine as you state above. And whom do you consider a woman of "average risk" of breast cancer? Eighty-five percent of women diagnosed with breast cancer have no identifiable risk factors, such as family history. Every woman is at risk. Are you aware that there has been a 400% increase in breast cancers in women younger than 40? Did the task force look at these numbers? Did the task force consider that one-third of women do not have access to mammography? Did the task force consider the increasing number of women being diagnosed with breast cancer. No, mammography may not be the best tool we have, but for now, it's the only tool we have. Go out and ask any woman -- would you rather have a false positive or would you rather wait a few years to have your breast cancer diagnosed, perhaps when it's spread to your lymph nodes? Would you rather have a benign biopsy or be diagnosed with stage IV cancer that could have been diagnosed earlier. Breast cancer is the leading cause of cancer death in women ages 15 to 54. But you're saying it's ok to lose a few of these women, just so we don't upset a few others with a false positive. Sad.

Respectfully, I think that your reasoning is flawed. No screening or diagnostic test captures every afflicted patient with precision. Of course, we will miss some women with the current mammography guidelines. There is a reason that we don’t advise mammography on women in their 30’s or colonscopy is folks in their 40’s, even though individuals in these age ranges can rarely develop these diseases. I think that you are minimizing the consequences of false positive mammography readings and exaggerating the benefits of this examination.

@lee - we don't know what would've happened had somebody went to better surgeons or not. We deal with here and now and the doctors people have access too. If and when there are treatments that have fewer side effects, the data may look different. But today we need to deal with the data we have. Additionally, any cancer diagnosis has negative effect on your quality of life and most cancer treatments aren't exactly good for your health. Overdiagnosis is a proven phenomenon, and only epidemiologists can estimate the extent. They are also the most objective.

Anon - I found it interesting how your post completely ignores overdiagnosis and minimizes the negative effect of false postiives? How much this increase in breast cancer incidence is due to overdiagnosis? Do you understand that screening - any screening - always increases incidence? Even if we forget about overdiagnosis, just a simple fact that the incidence of cancers increases with age and that screening shifts this age would result in slightly increased incidence. If you add overdiagnosis to it...

As to what women would prefer. I think most women don't really understand how small a chance they personally would benefit is and how high a chance of a false positive is. I saw women posting getting really upset when they learned that the cumulative chance of at least one false positive over 10 years is close to 50%. Or that they can be diagnosed with cancer unnecessarily... There is NO information about overdiagnosis in the media, including in doctors' interviews; when there is some information, the rate is grossly underestimated.

Re: Secretary Sebilius abandoning "her team" as posted much earlier; Most of what I heard from her (and other Obamacare advocates) was that these were all GWB appointees, thereby they must be in error and any of their conclusions should be dismissed as radical.

So Diora: Would you agree that for those of us who can read and understand the literature, at least to some extent, and feel we can find good practitioners, we should get mammograms and PSA tests because they can save our lives or prevent a life of fighting invasive cancer, if properly utilized, while for those of us who are too ignorant ro understand the options, or too trusting to find good doctors it's better that we not get screened and instead pray and bury our heads in the sands. I guess I can agree with that.

I'm the rare woman who doesn't participate in cancer screening. The profession would paint me as uneducated, lower-class and ignorant.I guess they are value judgments, but I'm definitely not uneducated. I have an LLM in Law and work as an investigative lawyer.

Screening has never been "offered" to women with full disclosure.It's usually demanded or "required" and unethical practices seem to be instantly overlooked, if it results in wider coverage.I strongly disagree with the accepted practice of inflating the benefits of screening and glossing over any risk and the use of scare campaigns. I wanted the truth and had to go looking for it myself. That shouldn't be necessary...Over the years, I've watched with dismay the various unethical tactics used by the profession to "increase coverage" and witnessed so many women being harmed by false positives and over-treatment. Informed consent is missing from breast and cervical screening.It's about time some honesty and respect was introduced into cervical and breast cancer screening.Men are not treated in this way. My husband was given a pros and cons chat and the decision to screen was left with him. His doctor is not paid to reach a target for prostate screening nor will he lecture or try to frighten my husband. Yet the risk of prostate cancer is as high as breast cancer and vastly more common than cervical cancer. Ironically, the most pressure is reserved for an uncommon cancer, cervical cancer. (I saw recently some statistics - 200,000 cases for breast and prostate, 11,000 for cervical and about 8600 for testicular cancer) Cervical cancer gets the most air time and is greatly feared, out of all proportion to risk. Testicular cancer is rarely mentioned by the profession. Men don't seem to walk around fearing testicular cancer, yet most women are greatly concerned about cervical cancer. Other more likely threats to their health are neglected or overlooked. The message has always been cervical cancer is a huge threat to all women. In fact, Angela Raffle, UK based cancer screening expert, released figures that put the risk into perspective...1000 women need regular screening for 35 years to save ONE woman from cervical cancer. (published in the BMJ)I know women who smoke heavily, but fear cervical cancer, not lung cancer that affects 1 in 25 women. (cervical is one in 200 in Australia) The scare campaigns have worked a treat and have resulted in far too much attention for this cancer and a misallocation of precious health resources. We are more likely to die from almost any other type of cancer. Many more lives could have been saved focusing on more common cancers and other health problems. Ever more resources are being poured into the "fight against cervical cancer"...DNA/HPV testing, liquid paps, Gardasil vaccinations - it seems never-ending. Risk information for PSA testing emerged fairly quickly. We're still waiting for the risks of cervical screening and we're just starting to hear about the risks of mammograms.I've just been offered the FOT...Yes or No...not sure yet, but you can be sure I'll be doing my research before I submit my healthy body to any screening test - they so often lead to very unpleasant, painful and harmful places. Informed consent is only possible when patients understand the risk of the cancer, the likelihood of benefiting from the test, the risk factors for the cancer and the risks of testing. (false positives and false negatives & the risks associated with biopsies and over-treatment)We're still a long way from that, a very long way.

Lee, I didn't have time to read or answer posts for a while. As far as I know there is no way today, no matter how great the practitioner is, to avoid false positives and overdiagnosis, so I really don't know in which dream world you are planning to find a practitioner that can give you answers science isn't able to give. Until the science is able to predict which cases of cancer would progress, you are going to have overdiagnosis. Since there is zero evidence that PSA even reduces mortality from prostate cancer, I am a bit skeptical of your ability to save your live by doing this test.

So please don't misinterpret what I said to mean what you want it to mean.

For the record - as the last anon, I am an educated woman - with MS/CS, working in world-famous corporate research center. I have my name on some papers, and I also have some patents, so I'd imagine while I am a lay person with regards to medicine, I still have above-average intelligence. Also, I had sufficient math background to understand rather elementary statistics required to read and understand the literature. I also have good insurance.

Given that, after careful review of data, I decided to forgo mammograms at least until I am 50, and quite likely thereafter. The risk of having become a cancer patient unnecessarily beats for me the much smaller chance of my benefitting from the test. When and if there is different data abvailable, I'll reconsider.

I don't forgo all screening tests. For example, I'll probably do colonoscopies. But regardless of what I'd personally choose or not choose to do, I strongly believe that screening is a personal choice. In our society, we are more likely to encounter pressure to be screened. This is wrong.

As to "those too ignorant to understand", I believe they should be explained both benefits and risks of each test so they aren't ignorant and are able to make their own informed decision.

Dr. Kirsch,I appreciate that you are consistent in questioning the validity of mammography and PSA tests (as well as your own specialty of colonoscopy)as you have the CT scans for lung cancer. In the future, I hope that you will accompany criticism of early screening for lung cancer with an emphasis on the need for a highly accurate detection system and better treatment, and not lend support to the widespread misperception that lung cancer is simply a matter of smoking prevention/cessation.

Thanks for your comment, Joyce. We agree. My point is that a bad screening or diagnostic test may be worse than no test. While I agree that many non-smokers are at risk for lung cancer, it is inarguable that the majority of cases are caused directly by inhaled primary smoke. Hence, a strategy to reduce lung cancer by reducing the number of smokers seems rather reasonable.

Dear Michael, thank you so much for your honest, unhysterical post. There are a group of women that is growing, who do not believe in this hysteria, and fully believe you can die WITH some of these cancers, as opposed to OF these things. We are also horrified about the lies, propoganda and total lack of informed consent regarding mammograms, and also the pap smear. It is lovely to hear an honest and researched viewpoint from a medical practitioner. Thank you so much.

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I am a full time practicing physician and writer. I write about the joys and challenges of medical practice including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When I'm not writing, I'm performing colonoscopies.